ERA19LA109

Factual narrative

On February 26, 2019, about 1835 eastern standard time, a Piper PA-28-181, N2184X, was substantially damaged when it was involved in an accident near Louisville, Kentucky. The private pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight. According to the pilot, after performing a preflight inspection, he taxied to the active runway for departure. He conducted an engine run-up; pretakeoff checklist and no anomalies were noted. Once he was cleared for takeoff, he advanced the throttle and began the takeoff roll. As the airplane accelerated through 60 knots and became airborne, the engine started to run "rough." He elected to land straight ahead on the remaining runway. The airplane over-ran the runway and collided with the perimeter fence. An examination of the airplane by a Federal Aviation Administration inspector revealed that the left wing was broken away from the fuselage. The outboard section of the right wing, which included the aileron, was broken away from the wing assembly. The vertical stabilizer was also separated from the empennage. While examining the engine, the propeller was rotated through 360° of motion and spark was noted at each of the spark leads. The left magneto was removed and two ignition wires in the distributor cap revealed evidence of arcing. One ignition lead was found detached from the insulator and the spring. The right magneto was removed and rotated and produced spark at each lead. The metal copper electrode on the right magneto distributor gear was found loose. Slick/Champion Aerospace Service Bulletin (SB)1-15A (issued July 2, 2015, and revised November 12, 2018) indicated a potential decreased service life of Slick 4-cylinder magneto distributor gear assemblies and was based on a limited number of field reports and product returns. Typical symptoms are unusual rpm drops during magneto check, difficulty starting the engine, or rough running engines. The anomaly was observed in magnetos with a varying number of service hours. The SB called for replacing affected distributor gear assemblies that have a copper electrode with assemblies that incorporate a Monel distributor gear electrode. The accident airplane’s engine was equipped with serial numbers 4370 and 4371 magnetos, which are in the range of affected magnetos indicated in the SB. A review of the maintenance logbooks revealed an entry dated February 29, 2016, for an "excessive rpm drop of the right magneto" during run-up. No logbook entries were noted for the repair of the magnetos or compliance with SB1-15A. The airplane received three annual inspections since the release and the revision of the SB. According to the pilot, the airplane accelerated normally during the takeoff roll, became airborne, and the engine started to run "rough." He elected to land straight ahead on the remaining runway. The airplane subsequently overran the runway and collided with the perimeter fence. Examination of the airplane revealed it sustained substantial damage to the airframe. During an examination of the left magneto, two ignition wires in the distributor cap revealed evidence of arcing, and one ignition lead was found detached from the insulator and spring. The right magneto was removed, rotated, and produced spark at each spark lead. The metal copper electrode on the right magneto distributor gear was found loose. To address a potential decreased service life of Slick 4-cylinder magneto distributor gear assemblies, Slick/Champion Aerospace Service Bulletin SB1-15A calls for replacing distributor gear assemblies that have a copper electrode with assemblies that have a Monel electrode. A rough running engine was a symptom of the condition that the SB was intended to address. A review of the accident airplane’s maintenance logbooks revealed no entries for the repair of the magnetos or compliance with the applicable SB and that the airplane received three annual inspections since the release and the revision of the SB. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

FAA avdata. C = Cause, F = Factor.

• C Aircraft-Aircraft power plant-Ignition system-Magneto/distributor-Failure
• — Personnel issues-Task performance-Maintenance-Replacement-Maintenance personnel